Calling the shots

In 1999 Dr. David Kim surveyed the medical landscape in Staten Island, N.Y., and noted a presence and an absence. Present: high rates of diabetes, obesity, heart disease, and asthma. Absent: Christianity. Kim decided to open a clinic but knew he could not do so with private contributions. In 2006 he founded Beacon Christian Community Health Center, a nonprofit clinic he hoped would become a federally qualified health center (FQHC) and receive grants from Washington.

The process of applying for nonprofit status under the state health department began with securing a site, an empty warehouse-but then Kim learned he could not renovate it until the health department received his plans and approved them, which took months. When the renovation was complete, the state had to sign off on it. The entire process took two years. During that time he housed the clinic in a temporary space above the local post office. Ill or elderly patients would say, "Dr. Kim, it's really good to see you, but those 17 steps. …"

Next, Kim and his staff had to prove they could provide primary and preventative care, have a paid core staff, and maintain accessible hours. Kim waded through the extensive application process and overcame considerable political opposition. At one point a bureaucrat told him to join a different community health center where he would not be allowed to put his Christian beliefs into practice.

Later, a New York health department staffer couldn't even imagine how faith and medicine could work together. He called to ask, "Do you do exorcisms? Do you use holy water? Do you immerse people in it?" But Kim's perseverance paid off, and Beacon became the first federal and state licensed faith-based clinic in New York state.

Beacon is not the only explicitly Christian FQHC: so is Lawndale in Chicago, Esperanza in Philadelphia, and Christ Community in Memphis. They serve in poor, medically underserved areas, which is one requirement for becoming an FQHC. Federal grants help these clinics provide care to the uninsured, and higher Medicaid and Medicare reimbursements make it economically feasible to care for the poor. Kim says the grants "are a bit of a bureaucratic nightmare. If there is something we can fund with patient revenue, we do so to avoid tight regulation."

In return for a steady funding stream, FQHCs must offer comprehensive medical care, including mental health and substance abuse treatment. They must report statistics about patients and procedures: Doctors generally see 15-20 patients per day. Clinic patients must form a majority of an FQHC's governing board. (The Beacon board includes a Sri Lankan, a Nigerian, a firefighter, and a retired church secretary: Kim and his staff joke that they have the diversity of the entire UN sitting in their waiting room.) About 1,100 FQHCs exist nationwide. Since each one can have multiple locations, that means about 8,000 total sites.

Volunteers at privately funded clinics speak often about the joy of practicing medicine without worrying about paperwork and complicated billing codes for Medicaid and insurance reimbursements. They bemoan the business of medicine, which results in doctors having to deal with many different insurance companies, each with its own rules, and with government directives.

Many Christian clinics, like Bethesda in Tyler, Texas, maintain their freedom by relying entirely on private funds. Executive director John English says, "As a Christian clinic we didn't want to have anything that would limit what we do. We didn't want to be dependent on any one resource." Bethesda relies on support from churches, individuals, and foundations, as well as a small patient co-pay, to meet its annual $1.2 million budget.

Pat White, executive director of the West Virginia Health Right clinic, expressed bluntly the view of many charity clinic supporters: "I don't like jumping through hoops." She sees charity clinics as bottom-up organizations, while FQHCs are "very top-down." She says the 200 doctors and dentists who volunteer at her clinic don't like Medicaid: "They fight Medicaid in their private practice. They don't want to do it when they volunteer." She gives an example of how her clinic works: "This afternoon we have a cardiologist. He'll see 16 patients that other doctors have referred. We don't have to get any Medicaid approvals. We just schedule them. It's a different practice type: patient-focused rather than payment-focused."

Charity clinics don't have billing systems. They either suggest nominal fees or accept donations - but they don't bill patients who can't pay. It's an honor system. White says patients appreciate the doctors who volunteer, and the doctors enjoy having patients say, "Thank you." She says many "impoverished people on Medicaid have to jump through so many hoops, they feel I'm entitled. …"

One looming concern for charity clinics: What will be the effect of the Affordable Care Act ("Obamacare")? The law gives much more money to FQHCs, causing some free clinics to rethink their mission. Should they become FQHCs or remain as they are? As Pat White put it, "Do we morph into something else? Or stay true to our mission?"

Michael Sowyak, executive director of Shelter Health Services in Charlotte, decided he does not want to change to a business model by chasing Medicaid reimbursements: "If we did that, we wouldn't be able to take 45 minutes for someone who needs extra help. … It would be 10 to 15 minutes per person, get them in and out, to maximize revenue. … They need more than just coming and getting a prescription. They need to have their hand held. They need to be shown respect."

Peggy Dator, president of the Free Clinic Association of Pennsylvania, says some clinics in her network might try to become FQHCs because they struggle to recruit enough volunteer staff. Dator also serves as executive director of a large free clinic in Doylestown: "The clinic I work with partners with a hospital, so we have an overabundance of volunteers. That's not true even half an hour north."

Even if they wanted to become FQHCs, she says, some free clinics might not be located in areas that qualify as underserved: "There are poor people all over, but we just aren't poor enough."

John Mills is managing director of Empowering Community Healthcare Outreach (ECHO), an organization that helps churches and other nonprofits to open medical clinics for the poor. Since 2005, the Fort Worth-based nonprofit has helped plan or open 48 medical clinics around the country, sending consultants to work at no charge with interested people in rural and urban communities.

Mills says even if a charity clinic wants to become an FQHC, funding isn't likely to be available: "It's still going to be really competitive. … Extremely unlikely that you are going to be funded. The money will be going to expansion of existing clinic sites." He sees FQHC paperwork as onerous-"Doing the basic reporting for Medicaid requires a staff to do just that"-and a major downside for doctors who want to practice medicine without having to think about the federal middleman.

Susan Post, executive director of Esperanza Health Center in Philadelphia, says her clinic, which serves a mostly Hispanic population, became an FQHC in 2006. She says government grants for the uninsured and government malpractice insurance help her clinic provide good care. She says what Esperanza wants the government has wanted: 24/7 accessibility, comprehensive care for the whole person, and integrated social services. She even sees an upside to the detailed end-of-year reports the government demands, calling them management tools: "Those are the kinds of things I ought to be doing."

Esperanza's leaders did not want to risk the clinic's explicitly Christian personality, so they highlighted the clinic's Christian mission in their application-and so far, Post says, government money has not changed the mission or its expression. Clinic staffers "offer prayer a lot." Most patients want staff members to pray with them because they "want the Lord in their lives." But Post is aware of recent government actions that threaten freedom of conscience: "We'd rather walk away than change the way we practice," she says, but doing so would "be hard … a very difficult thing."

And there's the danger. If Congress overturns the Hyde and Weldon Amendments, which guarantee that FQHCs don't have to perform or refer for abortion, Christian clinics will be in trouble. The same goes if Congress or an administration acts to prevent FQHCs from hiring people who share their mission. For example, FQHC groups have to tell patients where they can obtain contraceptives, but they don't have to provide contraceptive services themselves. That could change-and as Post acknowledges, walking away from the money would be hard.

Of course, these days even privately funded charity clinics have to navigate tricky waters to provide healthcare for the poor. Diane Steward of Puget Sound Christian Clinic notes some of the hurdles: "We've talked with lawyers, insurance agents, pastors and church administrators, negotiating agreements to use space in several churches and nonprofits and provide healthcare together. ... We called city licensing departments in several different communities to ensure we are meeting all legal and licensing requirements in each community."

But at the end of the day, private charity clinics answer only to their patients and funders-not to bureaucrats or legislators who have become increasingly hostile to religious expression: Just ask Catholic Social Services in Boston whether it's still able to provide adoption and foster care services.